Finalization of Guidelines for Laboratory Diagnosis of Anthrax

(1)

SEA-HLM-357 Distribution: Limited

Finalization of Guidelines for Laboratory Diagnosis

of Anthrax

Report of an Informal Consultation Bangkok, Thailand, 20-22 August 2002

Project No.ICP DDP 002

(2)

World Health Organization

Regional Office for South-East Asia New Delhi

October 2002

(3)

2

This document is not issued to the general public, and all rights are reserved by the World Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO.

No part of this document may be stored in a retrieval system or transmitted in any form or by any means  electronic, mechanical or other  without the prior written permission of WHO.

The views expressed in documents by named authors are solely the responsibility of those authors

(4)

Page

1. INTRODUCTION... 1

2. OBJECTIVE... 1

3. INAUGURAL PROGRAMME... 1

4. CONSULTATION ... 2

4.1 Regional Status... 4

5. RECOMMENDATIONS... 6

5.1 To Member Countries... 7

5.2 To WHO... 8

Annexes 1. List of Participants ... 9

2. Programme ... 11

(5)

(6)

1. INTRODUCTION

An Informal Consultation to finalize the Manual on Laboratory Diagnosis of Anthrax was organized at Bangkok, Thailand, from 20 to 22 August 2002. It was attended by microbiologists from all the countries of the South East Asia Region of WHO except Myanmar and the Democratic People’s Republic of Korea. Experts from the United Kingdom, the Regional Office for South-East Asia and WHO/Headquarters facilitated this consultation. The list of participants is at Annex 1 and the detailed programme of work at Annex 2.

2. OBJECTIVE

The objective of the consultation was to finalize the Manual on Laboratory Diagnosis of Anthrax.

3. INAUGURAL PROGRAMME

The inaugural programme was attended by all the participants, experts and some scientists from the Department of Medical Sciences, Ministry of Public Health, Thailand. Dr Rajesh Bhatia WHO Short-term Professional, SEARO welcomed the participants and briefed them about the activities undertaken by the Regional Office in the recent past to provide technical support to Member Countries in strengthening their capabilities for the management

(7)

Report of an Informal Consultation

Page 2

of anthrax. He also described the objectives and mechanism of the consultation.

Mr Narintr Tima, Monitoring and Evaluation Officer, WHO country office in Thailand read out the address on behalf of Dr Uton Muchtar Rafei, WHO Regional Director, South-East Asia Region. In his address, Dr Uton emphasized the need for efficient laboratory support for the diagnosis of anthrax. He stated that Member Countries of the Region already possessed considerable infrastructure in the form of institutions of public health and excellent laboratories that had been created over the past few decades. Most of these institutions were, in one form or another, undertaking activities related to the control of communicable diseases. However, the handling of anthrax as well as many other such organisms with high communicability, required specialized infrastructure and requisite expertise. Laboratory skills for anthrax were specialized and vital. These must be maintained and kept in a state of readiness to provide diagnostic services when needed. In view of the recent importance of anthrax as an agent that can be deliberately used to harm health, it was imperative to have a good laboratory infrastructure, skilled manpower and comprehensive guidelines to help bacteriologists in undertaking their tasks efficiently. This consultation had been designed to fulfil the need of a Manual on Laboratory Diagnosis of Anthrax that could be adapted by Member Countries.

4. CONSULTATION

Dr O. Cosivi (WHO/HQ) gave a global overview of the threat of deliberate use of micro-organisms to harm human health, with

(8)

Finalization of Guidelines for Laboratory Diagnosis of Anthrax special reference to anthrax. Among hundreds of possible micro- organisms, only a few are considered as having the potential of being used deliberately to harm humans. Dr Cosivi elaborated upon WHO’s role in containing known infections, responding to unexpected health situations and enhancing the preparedness of the Member Countries. He also briefed the participants about the global networks that WHO utilizes in meeting its mandate. The process of publication of the weekly Outbreak Verification List and support to Member Countries in the investigation and containment of outbreaks was also described by him. He informed the meeting that the second edition of the WHO publication “Public Health Response to Biological and Chemical Weapons: WHO Guidance”’

prepared in collaboration with more than 90 experts from all WHO regions, other international organizations, academia and NGOs was going to be published soon. Key information on agents which can be deliberately used to damage health was available on the WHO web site http://www.who.int/emc/deliberate_epi.html. WHO was also working with the UN Disaster Management Training Programme in developing a training module on the management of preparedness and response programmes on chemical and biological incidents. He welcomed the initiative of the Regional Office in developing a manual on laboratory diagnosis of anthrax which was very relevant in the context of the global efforts planned by WHO Headquarters for improving the state of preparedness of Member Countries, particularly in regard to the ongoing work on selected biological agents in order to strengthen networks on disease experts and laboratory and developing/reviewing standards (e.g. guidelines), information and training material on these agents.

(9)

Page 4

Dr Peter Turnbull (UK) traced the history of potential biological weapons with special reference to anthrax. According to available data, during the period 1900 to 2001, there had been 271 events wherein deliberate use of biological agents to cause harm to health was attempted. Of these, evidence in regard to the use of anthrax could be gathered in only seven instances. Dr Turnbull emphasized that though it was difficult to deliberately use anthrax bacilli to cause damage to human health because of numerous technical and logistical issues, it would be prudent for all to maintain a state of preparedness. He described the alertness and response mechanism that was currently in place in the United Kingdom and suggested that the same could be adapted by other countries. He informed the meeting that the revised version of WHO Guidelines for the Surveillance and Control of Anthrax in Humans and Animals (earlier version is of 1998) incorporating new techniques and knowledge might be available by mid-2003.

4.1 Regional Status

The status of infrastructure and expertise available in regard to anthrax in the Member Countries of the Region is given in Table 1.

Table 1: Anthrax capabilities in the countries of the SEA Region

Description BAN BHU INO IND MAV NEP SRL THA

Occurrence of human

cases of anthrax No Yes Yes Yes No No No Yes

Number of human cases in 2002

0 0 NA 5 0 No No NA

Occurrence of anthrax in animals

Yes Yes Yes Yes No No Yes Yes

(10)

Finalization of Guidelines for Laboratory Diagnosis of Anthrax

Outbreak of anthrax in animals

Yes NA Yes Yes No No Yes Yes

Containment level of lab: P3/P2/None

0 0 P2 P3/

P2

P2 P2 P3 P3

Number of clinical samples processed for anthrax in 2002

NA 0 NA 8 0 0 1 7

Number of

environmental samples tested for anthrax in 2002

0 0 NA 50+ 0 0 4 242

Isolation of anthrax bacilli

0 No Yes Yes No No No Yes

Tests employed for diagnosis

• Presumptive diagnosis (P)

• Confirmatory diagnosis ©

Nil P C C P P P C

Professionals trained in anthrax

No No Yes Yes No No No Yes

Availability of SOP for anthrax outbreak or handling of post having suspected contaminated material

No No Yes No No No Yes Yes

Nationally coordinated disaster management program exists

Yes No Yes Yes Yes Yes Yes Yes

(11)

Page 6

Stock of anthrax specific antimicrobial agents

Yes Yes Yes Yes Yes No Yes Yes

National guidelines for anthrax available

No No Yes Yes Yes No Yes Yes

The above Table shows gross inadequacies in the technical capabilities and infrastructure required to diagnose anthrax in the countries of the Region.

The draft manual on laboratory diagnosis of anthrax was thoroughly discussed by the participants and changes, as agreed upon by all, were incorporated in the draft to finalize it.

5. RECOMMENDATIONS

The consultation highlighted the inadequacies that exist in the state of preparedness in Member Countries in the laboratory diagnosis of anthrax. It appreciated the efforts made by WHO at the global and regional levels to enhance the capabilities of Member Countries in meeting the challenge of various biological agents that have the potential for deliberate use to cause damage to human health, especially anthrax.

It was also observed that, as compared to many other communicable diseases of public health importance, anthrax may not have considerable magnitude. However, the impact of possible use or threat to use anthrax as deliberate infection has

(12)

Finalization of Guidelines for Laboratory Diagnosis of Anthrax implications in terms of panic and fear of the public, adverse effect on trade and commerce and loss of credibility of health services.

To respond effectively to such a complex threat, encompassing national security and public health, priority should be given to upgrade the infrastructure and skills in all the countries. With this background, the meeting made the following recommendations:

5.1 To Member Countries

(1) Member Countries should create a suitable infrastructure and maintain it for efficient public health laboratory services to meet the challenge of various biological agents that can be deliberately used. Countries should also maintain a state of preparedness to effectively mount a rapid response to any occurrence of harm due to deliberate use of anthrax bacilli and other agents. Appropriate resources for achieving this recommendation should be allocated. The upgraded infrastructure and skills should also be beneficial in responding to outbreaks of other communicable diseases.

(2) Member Countries should adopt the Manual on Laboratory Diagnosis of Anthrax which shall provide practical steps for laboratory aspects that can be implemented at various levels of laboratories

(3) Handling and processing of material suspected to be having anthrax bacilli, especially environmental material requires a high level of containment in microbiology laboratory. Member Countries must have at least one such reference laboratory with biological safety level 3 (BSL-3) to handle such material and to prevent inhalation anthrax. This laboratory should also be useful in processing many other important pathogens that require BSL-3 level containment. Handling of clinical material

(13)

Page 8

may be done at BSL-2 level if BSL-3 facilities are not available using a class III safety cabinet.

(4) Networking of laboratories in the Region should be established.

One regional reference laboratory should be identified. Each country should have at least one reference laboratory for establishing confirmatory diagnosis and providing technical support to other laboratories in the country.

(5) Public health microbiologists and clinical epidemiologists should be trained in each Member Country to improve their skills in the diagnosis and management of anthrax.

5.2 To WHO

(1) WHO should publish the Manual on Laboratory Diagnosis of Anthrax and make it available to all the Member Countries as soon as possible.

(2) A hands-on training course of five days’ duration, should be organized for national trainers, in various laboratory techniques for diagnosis of anthrax and isolation of anthrax bacilli from environmental specimens.

(3) WHO should facilitate exchange of information and support networking of laboratories in the Region as well as establish linkages of regional network with the proposed global network.

(4) A workshop should be organized to orient Member Countries on the establishment of containment laboratories.

(5) WHO should conduct a training course for national trainers on efficient use of containment facilities, once these are established.

(14)

Annex 1

LIST OF PARTICIPANTS

Bangladesh Dr Md Moyez Uddin Virologist

Head of Microbiology Laboratory Institute of Public Health

Mohakhali, Dhaka

e-mail: banlab@bdonline.com Bhutan

Mr Karma Tshering

Laboratory In-charge, Microbiology JDWNR Hospital

Thimphu

e-mail: Karma_sang@hotmail.com India

Dr Veena Mittal

Joint Director (Microbiology) National Institute of Communicable Diseases

22, Sham Nath Marg Delhi-110 054

e-mail: surbhimittal@vsnl.net Dr M.K. Lalitha

Professor of Microbiology

Department of Clinical Microbiology Christian Medical College and Hospital Vellore-632 004

e-mail: mkl_micro@yahoo.com

Dr H.V. Batra

Head of Microbiology

Defence Research Development Establishment

Gwalior

H_V_batra@rediffmail.com

Indonesia

Dr Gunawan Yamin

Head, Division of Microbiology Directorate of Health Labs, Ministry of Health

JL H.R. Rasuna Said Jakarta

gyamin@cbn.net.id Maldives

Ms Shareefa Manike

Assistant Director Laboratory Services Indira Gandhi Memorial Hospital Male

e-mail: shareefamanike@hotmail.com Nepal

Dr Chandrika Devi Shrestha Sr. Pathologist

Nepal Public Health Laboratory Ministry of Health

(15)

Page 10

Teku, Kathmandu adsh@ntc.net.np Sri Lanka

Dr Pranitha Somaratne Medical Research Institute Colombo Sri Lanka e-mail: kiyo@sti.lk Thailand

Mrs Surang Dejsirilert

Head of Miscellaneous Bacteriology Laboratory

National Institute of Health Department of Medical Sciences Ministry of Public Health

Tiwanon Road, Nonthaburi 11000 e-mail: sudejsi@health.moph.go.th United Kingdom

Dr Peter Turnbull

Arjemptur Technology Ltd C/O 86 St Mark’s Avenue Salisbury, Wiltshire SP1 3DW

United Kingdom

peterturnbull@tesco.net

WHO Secretariat Dr Ottorino Cosivi, CDS/CSR/EPH

World Health Organization Avenue Appia, 20

1211 Geneva Switzerland Phone: +41 22 791 2531 Fax: +41 22 791 4893 e-mail: cosivio@who.int Dr Rajesh Bhatia Short Term Professional

Regional Office WHO South East Asia IP Estate

New Delhi 110 002

Phone: 3370804 ext 26504 e-mail: bhatiaraj@whosea.org Mr Narintr Tima

Programme Monitoring and Evaluation Officer

WR Thailand Office Nonthaburi,

narintr@whothai.org

(16)

Annex 2 PROGRAMME

Date/Time Topic Principal Speaker

20 August 2002

0900 Registration

0900 Inauguration

Objectives RD’s address Introduction

Election of chair and rapporteur

1030 WHO/HQ CSR initiatives in anthrax

Dr Cosivi 1100 Global experience in handling

suspected anthrax

Dr Turnbull

1130 WHO/SEARO initiatives in anthrax

Dr Rajesh Bhatia

1145 Overview of draft guidelines on anthrax

Prof Lalitha 1330 Discussions on draft document

on laboratory diagnosis of

(17)

Page 12

anthrax

1515 Discussion contd 21 August

2002

0900 Rapid dot ELISA technique in anthrax

Dr Harsh Batra

0930 Discussion on draft document 1045 Discussion on draft document 1300 Discussion on draft document 1515 Discussion on draft document 22 August

2002

0900 Status of laboratories in SEAR countries for diagnosis of anthrax -

Existing infrastructure in terms of man, machine, material and methodology

Country

representatives

1045 Status contd…

1300 Outline of final document Prof Lalitha

(18)

1400 Recommendations for use of documents

Rapporteur

1515 Concluding session Chairman

Finalization of Guidelines for Laboratory Diagnosis of Anthrax